Title 28. Insurance |
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TITLE 28. INSURANCE SUBCHAPTER T. SUBMISSION OF CLEAN CLAIMS §21.2801. Scope and Applicability. This subchapter applies to claims submitted by physicians or providers for covered services or benefits provided to insureds of preferred provider carriers and enrollees of HMOs, for the purpose of determining the starting point for the claims payment period set forth in Insurance Code Article 3.70-3C, §§3(m) & 3A, Article 20A.09(j) and Article 20A.18B. This subchapter applies to claims filed by physicians or providers after the effective date of this subchapter.§21.2802. Definitions. The following words and terms, when used in this subchapter shall have the following meanings, unless the context clearly indicates otherwise:(1) Clean claim -- A physician’s or provider’s claim for payment with documentation reasonably necessary for the HMO or preferred provider carrier to process the claim, which contains:(A) all of the required information set forth in §21.2803(a) of this title (relating to Elements of a Clean Claim);(B) the attachments of which the physician or provider has been properly notified as being necessary pursuant to §§21.2803(b) and 21.2804 of this title (relating to Disclosure of Necessary Attachments);(C) any additional elements of which the physician or provider has been properly notified pursuant to §21.2805 of this title (relating to Disclosure of Additional Clean Claim Elements) , and(D) the amount paid by the primary plan pursuant to §21.2803(d) of this title, if applicable.(2) HMO – A health maintenance organization as defined by Insurance Code Article 20A.02(n).(3) HMO delivery network – As defined by Insurance Code Article 20A.02(w).(4) Physician or provider --(A) with regard to a preferred provider carrier, a preferred provider as defined by Insurance Code Article 3.70-3C, Section 1(10) (Preferred Provider Benefit Plans).(B) with regard to an HMO,(i) a physician, as defined by Insurance Code Article 20A.02(r), who is a member of that HMO’s delivery network; or(ii) a provider, as defined by Insurance Code Article 20A.02(t), who is a member of that HMO’s delivery network.(5) Preferred provider carrier – An insurer that issues a preferred provider benefit plan as provided for by Insurance Code Article 3.70-3C, Section 2.(6) Primary Plan – As defined in §3.3506 of this title (relating to Use of the Terms "Plan," "Primary Plan," "Secondary Plan," and "This Plan" in Policies, Certificates and Contracts).(7) Secondary Plan – As defined in §3.3506 of this title (relating to Use of the Terms "Plan," "Primary Plan," "Secondary Plan," and "This Plan" in Policies, Certificates and Contracts).§21.2803. Elements of a Clean Claim.(a) Required Claim Information: The Health Care Financing Administration (HCFA) of the U.S. Department of Health and Human Services has developed claim forms which provide much of the information necessary to process claims. These forms have been identified by Insurance Code Article 21.52C as being required for the submission of certain claims. By providing the relevant information contained on the appropriate HCFA claim form specified in paragraphs (1) or (2) of this subsection to an HMO or a preferred provider carrier, along with any attachments and additional elements of which the physician or provider has been properly notified as being necessary pursuant to subsections (b) & (c) of this section, and §§21.2804 (relating to Disclosure of Necessary Attachments), and 21.2805 of this title (relating to Disclosure of Additional Clean Claim Elements), and the amount paid by the primary plan pursuant to subsection (d) of this section, if applicable, a physician or provider is submitting a clean claim. The appropriateness of the following HCFA claim forms, or their successor forms, is determined by the type of physician or provider and the type of service provided:
(b) Attachments. In addition to the information on the appropriate claim form set forth in subsection (a) of this section, HCFA has developed a variety of manuals that identify various attachments required of different physicians or providers for specific services. An HMO or a preferred provider carrier may use the appropriate Medicare standards for attachments in order to properly process claims for certain types of services. Before any attachments may be required, the HMO or preferred provider carrier must satisfy the notification procedures set forth in §21.2804 of this title (relating to Disclosure of Necessary Attachments).(c) Additional clean claim elements. Before any additional elements beyond the information on the claim form and attachments identified in subsections (a) and (b) of this section may be required, the HMO or the preferred provider carrier must satisfy the notification procedures set forth in §21.2805 of this title (relating to Disclosure of Additional Clean Claim Elements).(d) Coordination of benefits clean claim requirement. If a claim is submitted for covered services or benefits in which coordination of benefits pursuant to §§3.3501 – 3.3511 of this title (relating to Group Coordination of Benefits) is necessary, the secondary plan may by contract require as an element of a clean claim, from the physician or provider, the amount paid by the primary plan.(e) Format of elements. The required elements of a clean claim set forth in subsections (a), (b), (c) and (d), if applicable, of this section must be complete, legible and accurate.(f) Signature on file. The original signatures of patients, subscribers, physicians and providers, or their authorized representatives, required by the HCFA claim forms specified in paragraphs (1) and (2) of subsection (a) of this section are not necessary if original signatures are on file with the physician or provider.§21.2804. Disclosure of Necessary Attachments. In order for attachments described in §21.2803(b) of this title (relating to Elements of a Clean Claim) to be required as part of a clean claim, the HMO or preferred provider carrier must provide adequate written notice to all affected physicians or providers that such attachments are necessary. Such notice must identify with specificity the attachment(s) required, and must be received by the physician or provider at least 60 days before requiring such attachment as an element of a clean claim. If an attachment is identified as a required element of a clean claim in the contract between the HMO or preferred provider carrier and the physician or provider, then additional written notice is not required.§21.2805. Disclosure of Additional Clean Claim Elements. An HMO or preferred provider carrier may include in its contracts with physicians or providers a provision to require additional elements for clean claims. To require such additional elements as part of a clean claim, the HMO or preferred provider carrier must provide adequate written notice to all affected physicians or providers that such additional elements are necessary. Such notice must identify with specificity the additional elements being required, and must be received by the physician or provider at least 60 days before requiring such additional elements as an element of a clean claim.§21.2806. Effect of Filing a Clean Claim. The claims payment period begins to run upon receipt of a clean claim from a physician or provider at the address designated by the HMO or preferred provider carrier, whether it be the address of the HMO, preferred provider carrier, or a delegated claims processor.§21.2807. Disclosure of Processing Procedures. In their physician or provider contracts, an HMO or preferred provider carrier must disclose to its physicians and providers:(1) the address where claims should be sent for processing;(2) the phone number at which physicians’ and providers’ questions and concerns regarding claims may be addressed;(3) any entity to which the HMO or preferred provider carrier has delegated claim payment functions, if applicable; and(4) the address of any separate claims processing centers for specific types of services, if applicable.(b) An HMO must provide the information required in subsection (a) of this section in its physician or provider manuals.(c) An HMO or preferred provider carrier shall provide no less than 60 days prior written notice of any changes of address for submission of claims, and of any changes of delegation of claims payment functions, to all affected physicians and providers with whom the HMO or preferred provider carrier has contracts.§21.2808. Denial of Claims Prohibited for Change of Address or Administrator. After a change of claims payment address or a change in delegation of claims payment functions, an HMO or preferred provider carrier may not premise the denial of a claim upon a physician’s or provider’s failure to file a claim within any contracted time period for claim filing, unless timely written notice as required by §21.2808(c) of this title (relating to Disclosure of Processing Procedures) has been given. §21.2809. Requirements Applicable to Delegated Claims Processors. If an HMO or preferred provider carrier has delegated its claims processing functions to a third party, the delegation agreement must provide that the claims processing entity will comply with the requirements of this subchapter. |
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